God Bless the Psychiatrist

Someone once calculated how many hours it would take for a primary care doctor to go through all of the recommended screening evaluations, review of systems, health maintenance, and other items required at an annual physical, and it was at least a couple of hours (not the 20 minutes we have).

And that's not even allowing time for the questions our patients might have, disease management, addressing symptoms, and dealing with active issues discovered through all that screening.

Head to toe, we are made up of multiple organs, each of which could be covered by a subspecialist, each of whom has their own battery of screening questions, all of which take time. But the one subspecialty all of the practices involved in developing our patient-centered medical home have voiced an increased need for is behavioral health services.

One of my colleagues and oldest friends is a psychiatrist who has worked in some of the toughest psychiatric facilities in the country. She always says "God bless the internist for starting patients on an antidepressant, and damn the internist for starting patients on an antidepressant." They do not have the time to see all the patients with bread-and-butter depression, but we sometimes miss those cases that really needed more attention and intensive interventions, and sometimes, sadly, we're the ones who flip them into mania.

No matter what the underlying diagnosis, though, mental health issues are an incredibly important component of basic healthcare, and helping our patients uncover these issues will help lead them on a path to better health. Getting through these barriers of discovery, and then on to action and results, are some of the greatest challenges we face in caring for our patients.

In most models of the patient-centered medical home, medical assistants screen patients before their office visit and administer simple depression screening questionnaires, which if positive lead to longer, more formal testing at the practice. The primary care providers are provided with the results of these questionnaires, and are then faced with the daunting task of figuring out what needs to be done and then doing something about it.

Even if I know what they need, getting them what they need has proven more complex than we imagined.

We currently have several social workers and newly hired care coordinators working in our practice and a part-time psychiatrist who sees patients one day a week with our internal medicine residents.

Our social workers have a thick file of neighborhood behavioral health providers and after assessing patients will send them to these resources, although often with mixed results. In our own institution our patients are sent to the hospital's psychiatry practice, where patients are required to call first thing Monday morning to lock in one of very few available evaluation appointments.

Most of them are not organized enough to handle this and fail to even enter the system. These patients, already challenged, have an incredibly difficult time navigating the behavioral health system.

One of my patients, who was missing all of her appointments with her multiple doctors, was finally seen in psychiatry and formally diagnosed with agoraphobia in addition to her underlying anxiety and depression. She was shortly thereafter closed out of the psychiatry practice for failing to keep her appointments. Lost opportunity.

Some practices try to have a care coordinator and psychiatrist review all of the week's positive depression screens, and then divide patients up by acuity and severity, to guide them to appropriate treatment.

We are just so used to trying to get today's work done today, that the concept of adding people to a queue to fill a need as complex as mental health seems anathema to how we work.

We are tying to build a system such that as we get back positive screens, we have an outlet to actions that move things along briskly. Making people wait will lead to more missed care. "Seize the moment of enlightened opportunity," as they say. We need to be able to get our patients into care for mental health issues as quickly as we can get them a CT scan for abdominal pain. Why not?

Building a network of caring, compassionate mental and behavioral health providers who can see our patients in a timely fashion will lead to improved patient satisfaction, more buy-in from the providers, and hopefully more compliance and healthier patients moving forward.

This extension of the patient's care beyond the walls of our practice is the very nature of the patient-centered medical home. We cannot just add more screening questions to our visits without the outlets and the resources to get our patients the care they so desperately need.

We have begun the process of creating these networks and are adding the needed screening questions to our electronic health record,with plans to evaluate how often we are able to get patients into the care they need. Hopefully the addition of behavioral health will add so much value that our patient's overall health will be able to get the attention it needs.

This week's column is dedicated to my father-in-law, Neal R. Peirce, who is retiring after having written a weekly newspaper column for the past 38 years -- that's approximately 19,000 columns about important issues relating to cities, states, and regional government, and he has made an incredible difference in the lives of Americans as our country has changed over the past few decades.

I have witnessed his incredible dedication, passion, and work ethic. Every week, regardless of his other workload and family obligations, he pours himself into his column. Now after I've written a weekly column for only a few months, I've gained even more insight into what this work has required of him and what he's accomplished, and I'm incredibly proud of him and wish him the best of luck as he sets off on his new professional venture.

More in Building the Patient-Centered Medical Home

MedPageToday is a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of health care professionals.

Physicians and other healthcare professionals may also receive Continuing Medical Education (CME) and Continuing Education (CE) credits at no cost for participating in MedPage Today-hosted educational activities.